Provider Demographics
NPI:1639183825
Name:DEXTER, JACQULINE LIBBY (MSLP)
Entity Type:Individual
Prefix:
First Name:JACQULINE
Middle Name:LIBBY
Last Name:DEXTER
Suffix:
Gender:F
Credentials:MSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3137 HENNEPIN AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2602
Mailing Address - Country:US
Mailing Address - Phone:612-827-0777
Mailing Address - Fax:612-827-0777
Practice Address - Street 1:3137 HENNEPIN AVE STE 202
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2602
Practice Address - Country:US
Practice Address - Phone:612-827-0777
Practice Address - Fax:612-827-0777
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2837103T00000X
MNR083276163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8H854DEOtherBLUE CROSS BLUE SHEILD